CONSENT FOR CARE AND TREATMENT: Your Therapist will complete and evaluation by examination and Interview. Your Individual treatment program will then be designed. A variety of treatment techniques may be used. I reakce that I have the right to accept or refuse treatment offered to me. The undersigned do hereby agree and give my consent for the CENTER OF REHABILITATION EXCELLENCE to furnish care and treatment considered necessary and proper in treating my condition.

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize CENTER OF REHABILITATION EXCELLENCE to furnish information to insurance carrier and/or its representatives, attorney concerning this treatment and I hereby assign all payment for services rendered.

WORKERS COMPENSATION CLAIMS: If you CLAIM Workers' Comp benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you.

CANCELLATION & NO SHOW POLICY: CORE strives to provide each patient with the highest quality of care while attempting to accommodate your schedule for your convenience. Therefore, we provide reserved time slots for each patient in order to minimize waiting time and assure continuity of treatment. Your consistent attendance of the planned treatment regimen is paramount to your full recovery. Cancellation, especially last minute ones, along with patient no shows, decreases our ability to accommodate the scheduling needs of other patients.

• If you are unable to keep a scheduled appointment, we request that you notify us 24 hours in advance.
• All cancellations and no shows will be documented in your medical record and appropriately reported.
• If you accumulate 3 cancellations or no shows with in a 30 day period, you will be referred back to your physician for a new script.
• If you cancel or no show your appointment and there has been no contact for 10 business days, you may be discharged for non compliance and referred back to your physician.
• Initial Evaluation appointment times are crucial. If you are unable to attend at your scheduled time and are not able to reschedule then we must refer you back to your physician for a new script.

We believe this policy is necessary for the benefit of all patients so that treatment and service to everyone. can continue to provide high quality treatment and service to everyone.

FINANCIAL POLICY: We will bill all primary and secondary insurance companies. Please provide us with complete and accurate insurance information as well as any change of address, telephone number and change in coverage. You are responsible for your bill. We require that arrangements for are rendered in the event that payment of your estimated share you insurance company requests a refund of payments made be made at time services maybe responsible for the amount of money refunded to your insurance company. If any payment is made directly to you by the insurance company for services billed by us, you recognize an obligation to promptly remit payments to us. Your Insurance benefits as quoted to us by your insurance carrier have been reviewed with you. We assume no liability for any errors made by your insurance carrier in this quotation. We have reviewed these benefits with you and you agree to pay your portion of the bill. Statements will be sent out monthly and payments will be expected in a timely manner.

I have read and agree to the above standards and understand my responsibility for the payment of my account.